Sleep and mental health among youth experiencing homelessness: A retrospective pilot diary study.

OBJECTIVES: The goal of this study was to describe the nightly sleep conditions of youth experiencing homelessness, and examine the association between sleep and mental health, both cross-sectionally and using diary data. METHODS: n = 147 youth (ages 16-24) experiencing homelessness completed a baseline survey assessing self-reported sleep and depressive and anxious symptoms. A subsample of n = 49 completed a follow-up 7-day diary study measuring nightly sleep conditions and daily depressive and somatic symptoms. RESULTS: According to baseline data, the majority of the sample (71%) reported sleeping less than 7 hours per night on average, and feeling like they did not get adequate sleep, especially among youth identifying as LGBTQ. In a qualitative follow-up question, the plurality attributed poor sleep to mental health woes. Cross-sectionally, youth with lower levels of self-reported sleep quality (more daytime fatigue and insomnia) reported higher levels of depressive and anxious symptoms. The diary data indicated that the most common nightly complaints among shelter utilizers are lack of privacy, noise, and uncomfortable temperatures. Multilevel models suggest that poor sleep conditions predicted higher levels of somatic symptoms the following day, after controlling for baseline levels of depressive and anxious symptoms. CONCLUSIONS: This study highlights the role environmental context plays in sleep health and its subsequent impacts. Individuals experiencing homelessness lack autonomy over their sleeping environments, and thus cannot make adjustments such as reducing disruptions such as noise, temperature, and light. Importantly, these less-than-ideal sleeping conditions contribute to pre-existing health disparities and may have long-term implications.

Reduction in mortality from HIV-related CNS infections in routine care in Africa (DREAMM): a before-and-after, implementation study.

BACKGROUND: Four decades into the HIV epidemic, CNS infection remains a leading cause of preventable HIV-related deaths in routine care. The Driving Reduced AIDS-associated Meningo-encephalitis Mortality (DREAMM) project aimed to develop, implement, and evaluate pragmatic implementation interventions and strategies to reduce mortality from HIV-related CNS infection. METHODS: DREAMM took place in five public hospitals in Cameroon, Malawi, and Tanzania. The main intervention was a stepwise algorithm for HIV-related CNS infections including bedside rapid diagnostic testing and implementation of WHO cryptococcal meningitis guidelines. A health system strengthening approach for hospitals was adopted to deliver quality care through a co-designed education programme, optimised clinical and laboratory pathways, and communities of practice. DREAMM was led and driven by local leadership and divided into three phases: observation (including situational analyses of routine care), training, and implementation. Consecutive adults (aged ≥18 years) living with HIV presenting with a first episode of suspected CNS infection were eligible for recruitment. The primary endpoint was the comparison of 2-week all-cause mortality between observation and implementation phases. This study completed follow-up in September, 2021. The project was registered on ClinicalTrials.gov, NCT03226379. FINDINGS: From November, 2016 to April, 2019, 139 eligible participants were enrolled in the observation phase. From Jan 9, 2018, to March 25, 2021, 362 participants were enrolled into the implementation phase. 216 (76%) of 286 participants had advanced HIV disease (209 participants had missing CD4 cell count), and 340 (69%) of 494 participants had exposure to antiretroviral therapy (ART; one participant had missing ART data). In the implementation phase 269 (76%) of 356 participants had a probable CNS infection, 203 (76%) of whom received a confirmed microbiological or radiological diagnosis of CNS infection using existing diagnostic tests and medicines. 63 (49%) of 129 participants died at 2 weeks in the observation phase compared with 63 (24%) of 266 in the implementation phase; and all-cause mortality was lower in the implementation phase when adjusted for site, sex, age, ART exposure (adjusted risk difference -23%, 95% CI -33 to -13; p<0·001). At 10 weeks, 71 (55%) died in the observation phase compared with 103 (39%) in the implementation phase (-13%, -24 to -3; p=0·01). INTERPRETATION: DREAMM substantially reduced mortality from HIV-associated CNS infection in resource-limited settings in Africa. DREAMM scale-up is urgently required to reduce deaths in public hospitals and help meet Sustainable Development Goals. FUNDING: European and Developing Countries Clinical Trials Partnership, French Agency for Research on AIDS and Viral Hepatitis. TRANSLATIONS: For the French and Portuguese translations of the abstract see Supplementary Materials section.

Inoculum Preparation Conditions Influence Adherence of Salmonella enterica Serovars to Red Leaf Lettuce (Lactuca sativa).

ABSTRACT: Salmonella enterica has been increasingly linked to outbreaks involving consumption of fresh produce. Although researchers have identified genes whose products are involved in mediating S. enterica-plant interactions, the use of various experimental approaches, serovars, and plant types has generated variable and conflicting data. The purpose of this study was to determine whether conditions under which inocula are prepared for in vitro plant interaction studies influence the outcome of these studies. Seven S. enterica serovars were grown in media that differed in salinity and physical state with incubation at 25 or 37°C. These cultures were then used to inoculate red leaf lettuce, and adherent microbes were subsequently recovered. Although all Salmonella serovars were influenced by inoculum preparation conditions, the amount of variation differed. Analysis of pooled serovar data revealed that inocula prepared from either agar plates or biphasic cultures had higher levels of interaction with red leaf lettuce than those prepared from broth cultures. Incubation at 37°C enhanced adherence after 30 s or 5 days of contact time, and adherence after 1 h of contact time was increased in low-salt medium. Broth inoculum cultures were highly influenced by medium salinity and incubation temperature, whereas plate and biphasic inoculum cultures were only minimally affected. Therefore, inocula prepared from bacteria grown on plates or in biphasic culture would be most suitable for evaluation of strategies used to interfere with plant-Salmonella interactions. However, pooled data mask serovar-specific responses, and care should be taken when extrapolating these findings to individual serovars. The previous association of a serovar with outbreaks involving leafy greens was not correlated with levels of interaction with red leaf lettuce, suggesting that the occurrence of these serovars in or on these commodities does not reflect their fitness in the plant environment.

Expansive learning in medical education: Putting Change Laboratory to work.

This paper explores the purposeful use of conceptual and methodological tools provided by Cultural Historical Activity Theory (CHAT) to transform learning cultures and practices within and across diverse clinical learning environments. We describe how Change Laboratory methodology helped clinicians and others who support student, intern, and resident education to make changes collaboratively. A case study in undergraduate medical education shows how this created new forms of medical student placement and a postgraduate study shows how it addressed supervisors' undermining behaviour towards Obstetrics and Gynaecology residents. This empirical work illustrates ways of modifying the classical Change Laboratory process to fit local contexts, resources, and needs. We conclude with lessons learned and future directions for practitioner-researchers who wish to broaden the range of methodological tools they use to transform clinical learning environments.

Learning from interprofessional education: A cautionary tale.

BACKGROUND: Interprofessional education (IPE) is time consuming to develop and sustain and presents many logistical and practical challenges to curriculum developers. Drawing on findings from an evaluation study of an IPE pilot, this paper brings new insights into both positive implications and potentially negative consequences of delivering large scale IPE. OBJECTIVE: The aim of the study was to evaluate a large scale IPE pilot delivered to students in the first year of their training. DESIGN AND SETTING: The IPE pilot took place on campus and was focused on patient safety (human factors). PARTICIPANTS: The study involved 630 first year undergraduates across 10 programmes at a UK university. METHODS: A mixed methods evaluation was conducted comprising a paper-based survey circulated at the end of the taught session followed by uni-professional focus groups (n = 4). Questionnaire data was subject to descriptive statistical analysis and key themes were generated from the focus group data. RESULTS: Three overarching themes emerged from analysis of the qualitative data: Understanding differences in roles, Learning about stereotypes and Unintended perpetuation of stereotypes. CONCLUSIONS: IPE is an important part of the training of all health and social care professionals and the study revealed many benefits of this approach. However, we should be sensitive to the possibility of inadvertently perpetuating negative stereotypes as a consequence of IPE activities. Our work highlights the need for caution when considering the planning and executing IPE activities.

Ethical dilemmas and reflexivity in qualitative research.

CONTEXT: For medical education researchers, a key concern may be the practicalities of gaining ethical approval where this is a national or local requirement. However, in qualitative studies, where the dynamics of human interaction pervade, ethical considerations are an ongoing process which continues long after approval has been granted. Responding to ethical dilemmas arising 'in the moment' requires a reflexive approach whereby the researcher questions his/her own motivations, assumptions and interests. Drawing on empirical studies and their experiences in academic and clinical research practice, the authors share their reflections on adhering to ethical principles throughout the research process to illustrate the complexities and nuances involved. OBJECTIVES AND FINDINGS: These reflections offer critical insights into dilemmas arising in view of the ethical principles driving good conduct, and through domains which distinguish between procedural ethics, situational ethics, ethical relationships and ethical issues in exiting the study. The accounts consider integrity and altruism in research, gatekeeping and negotiating access, consent and confidentiality, power dynamics and role conflict, and challenges in dissemination of findings. The experiences are based on a range of examples of research in a UK context from managing difficult conversations in the classroom to video-ethnography in the operating theatre. DISCUSSION AND CONCLUSIONS: These critical reflections make visible the challenges encountered and decisions that must be taken in the moment and on reflection after the event. Through sharing our experiences and debating the decisions we made, we offer insights into reflexivity in qualitative research which will be of value to others.

Can the tools of activity theory help us in advancing understanding and organisational change in undergraduate medical education?

Continued changes to healthcare delivery in the UK, and an increasing focus on patient safety and quality improvement, require a radical rethink on how we enable graduates to begin work in challenging, complex environments. Professional regulatory bodies now require undergraduate medical schools to implement an 'assistantship' period in the final year of study, where senior medical students 'shadow' the work of junior doctors, with an expectation that they will be better 'prepared' for work. However, there is little guidance about what an 'assistantship' entails and the current emphasis on preparedness of students arguably underplays the importance of contextualised learning within the workplace environment. This paper will describe a modified Development Work Research (DWR) (Engeström in Developmental work research: activity theory in practice. Lehmanns Media, Berlin, 2005) approach to organisational change, enabling academic, clinical and administrative partners to develop assistantship placements in different hospitals. Our findings indicate that a modified DWR approach can reveal factors indicating organisational readiness to support change within a locally contextualised framework. The process has significant practical applications across a range of healthcare disciplines, as all professions seek to engage with the challenge of enabling successful transitions of graduates to the workplace.

Site-specific enzymatic polysialylation of therapeutic proteins using bacterial enzymes.

The posttranslational modification of therapeutic proteins with terminal sialic acids is one means of improving their circulating half-life, thereby improving their efficiency. We have developed a two-step in vitro enzymatic modification of glycoproteins, which has previously only been achieved by chemical means [Gregoriadis G, Jain S, Papaioannou I, Laing P (2005) Int J Pharm 300:125-130). This two-step procedure uses the Campylobacter jejuni Cst-II α2,8-sialyltransferase to provide a primer on N-linked glycans, followed by polysialylation using the Neisseria meningitidis α2,8-polysialyltransferase. Here, we have demonstrated the ability of this system to modify three glycoproteins with varying N-linked glycan compositions: the human therapeutic proteins alpha-1-antitrypsin (A1AT) and factor IX, as well as bovine fetuin. The chain length of the polysialic acid addition was optimized by controlling reaction conditions. After demonstrating the ability of this system to modify a variety of proteins, the effect of polysialylation on the activity and serum half-life of A1AT was examined. The polysialylation of A1AT did not adversely affect its in vitro inhibition activity against human neutrophil elastase. The polysialylation of A1AT resulted in a significantly improved pharmacokinetic profile when the modified proteins were injected into CD-1 mice. Together, these results suggest that polysialylated A1AT may be useful for improved augmentation therapy for patients with a deficiency in this protein and that this modification may be applied to other therapeutic proteins.

Mechanistic investigation of the endo-alpha-N-acetylgalactosaminidase from Streptococcus pneumoniae R6.

The large (1767-amino acid) endo-alpha-N-acetylgalactosaminidase from Streptococcus pneumoniae (SpGH101) specifically removes an O-linked disaccharide Gal-beta-1,3-GalNAc-alpha from glycoproteins. While the enzyme from natural sources has been used as a reagent for many years, very few mechanistic studies have been performed. Using the recently determined three-dimensional structure of the recombinant protein as a background, we report here a mechanistic investigation of the SpGH101 retaining alpha-glycoside hydrolase using a combination of synthetic and natural substrates. On the basis of a model of the substrate complex of SpGH101, we propose D764 and E796 as the nucleophile and general acid-base residues, respectively. These roles were confirmed by kinetic and mechanistic analysis of mutants at those positions using synthetic substrates and anion rescue experiments. pK(a) values of 5.3 and 7.2 were assigned to D764 and E796 on the basis of the pK(a) values derived from the bell-shaped dependence of k(cat)/K(m) upon pH. The enzyme contains several putative carbohydrate binding modules whose glycan binding specificities were probed using the printed glycan array of the Consortium for Functional Glycomics using the inactive D764A and D764F mutants that had been labeled with Alexafluor 488. These studies revealed binding to galacto-N-biose, consistent with a role for these domains in localizing the enzyme near its substrates.

Identification of Campylobacter jejuni genes contributing to acid adaptation by transcriptional profiling and genome-wide mutagenesis.

In order to cause disease, the food- and waterborne pathogen Campylobacter jejuni must face the extreme acidity of the host stomach as well as cope with pH fluctuations in the intestine. In the present study, C. jejuni NCTC 11168 was grown under mildly acidic conditions mimicking those encountered in the intestine. The resulting transcriptional profiles revealed how this bacterium fine-tunes gene expression in response to acid stress. This adaptation involves the differential expression of respiratory pathways, the induction of genes for phosphate transport, and the repression of energy generation and intermediary metabolism genes. We also generated and screened a transposon-based mutant library to identify genes required for wild-type levels of growth under mildly acidic conditions. This screen highlighted the important role played by cell surface components (flagella, the outer membrane, capsular polysaccharides, and lipooligosaccharides) in the acid stress response of C. jejuni. Our data also revealed that a limited correlation exists between genes required for growth under acidic conditions and genes differentially expressed in response to acid. To gain a comprehensive picture of the acid stress response of C. jejuni, we merged transcriptional profiles obtained from acid-adapted cells and cells subjected to acid shock. Genes encoding the transcriptional regulator PerR and putative oxidoreductase subunits Cj0414 and Cj0415 were among the few up-regulated under both acid stress conditions. As a Cj0415 mutant was acid sensitive, it is likely that these genes are crucial to the acid stress response of C. jejuni and consequently are important for host colonization.

Identification of Campylobacter jejuni genes involved in the response to acidic pH and stomach transit.

Campylobacter jejuni causes food- and waterborne gastroenteritis, and as such it must survive passage through the stomach in order to reach the gastrointestinal tract. While little is known about how C. jejuni survives transit through the stomach, its low infectious dose suggests it is well equipped to sense and respond to acid shock. In this study, the transcriptional profile of C. jejuni NCTC 11168 was obtained after the organism was exposed to in vitro and in vivo (piglet stomach) acid shock. The observed down-regulation of genes encoding ribosomal proteins likely reflects the need to reshuffle energy toward the expression of components required for survival. Acid shock also caused C. jejuni to up-regulate genes involved in stress responses. These included heat shock genes as well as genes involved in the response to oxidative and nitrosative stress. A role for the chaperone clpB in acid resistance was confirmed in vitro. Some genes showed expression patterns that were markedly different in vivo and in vitro, which likely reflects the complexity of the in vivo environment. For instance, transit through the stomach was characterized by up-regulation of genes that encode products that are involved in the use of nitrite as a terminal electron acceptor and down-regulation of genes that are involved in capsular polysaccharide expression. In conclusion, this study has enabled us to understand how C. jejuni modulates gene expression in response to acid shock in vitro and to correlate this with gene expression profiles of C. jejuni as it transits through the host stomach.

Can emergency nurses use the Canadian cervical spine rule to reduce unnecessary patient immobilisation?

The Canadian c-spine rule (CCR) allows safe, reproducible use of radiography in alert, stable patients with potential c-spine injury in the emergency setting [Stiell, I., Clement, C., McKnight, R., Brison, R., Schull, M., Lowe, B., Worthington, J., Eisenhauer, M., Cass, D., Greenberg, G., MacPhail, I., Dreyer, J., Lee, J., Bandiera, G., Reardon, M., Holroyd, B., Lesiuk, H., G. Wells, 2003. The Canadian c-spine rule versus the nexus low-risk criteria in patients with trauma. The New England journal of medicine 349 (26), 2510-2518; Stiell, I., Wells, G., Vandemheen, K., Clement, C., 2001. The Canadian c-spine rule for radiography in alert and stable trauma patients. JAMA 286 (15), 1841]. This paper reports on a study of emergency nurses' ability to identify patients requiring immobilisation using the CCR. Emergency department triage nurses (N = 112) were trained in the use of the CCR and then asked to use the tool over the following 14 months in the assessment of 460 patients who presented with potential c-spine injury. Trained medical staff repeated 55% of the clinical assessments independently using the rule. The level of agreement between nurse and medical judgement was calculated. The inter-rater reliability using the kappa statistic was 0.6 (95% CI 0.50-0.62 N = 254) indicating a 'good' level of agreement. The majority of nurses indicated they were comfortable using the rule. The results suggest that UK emergency department nurses were able to use the Canadian c-spine rule to successfully guide selective immobilisation. A 25% reduction in immobilisation rates would have been achieved if the rule had been followed. Further studies are needed to test the reduction in levels of immobilisation that could be achieved in clinical practice.

functional analysis of conserved gene products involved in assembly of Escherichia coli capsules and exopolysaccharides: evidence for molecular recognition between Wza and Wzc for colanic acid biosynthesis.

Group 1 capsular polysaccharides (CPSs) of Escherichia coli and some loosely cell-associated exopolysaccharides (EPSs), such as colanic acid, are assembled by a Wzy-dependent polymerization system. In this biosynthesis pathway, Wza, Wzb, and Wzc homologues are required for surface expression of wild-type CPS or EPS. Multimeric complexes of Wza in the outer membrane are believed to provide a channel for polymer export; Wzc is an inner membrane tyrosine autokinase and Wzb is its cognate phosphatase. This study was performed to determine whether the Wza, Wzb, and Wzc proteins for colanic acid expression in E. coli K-12 could function in the E. coli K30 prototype group 1 capsule system. When expressed together, colanic acid Wza, Wzb, and Wzc could complement a wza-wzb-wzc defect in E. coli K30, suggesting conservation in their collective function in Wzy-dependent CPS and EPS systems. Expressed individually, colanic acid Wza and Wzb could also function in K30 CPS expression. In contrast, the structural requirements for Wzc function were more stringent because colanic acid Wzc could restore translocation of K30 CPS to the cell surface only when expressed with its cognate Wza protein. Chimeric colanic acid-K30 Wzc proteins were constructed to further study this interaction. These proteins could restore K30 biosynthesis but were unable to couple synthesis to export. The chimeric protein comprising the periplasmic domain of colanic acid Wzc was functional for effective K30 CPS surface expression only when coexpressed with colanic acid Wza. These data highlight the importance of Wza-Wzc interactions in group 1 CPS assembly.

Physicians' knowledge of transdermal fentanyl.

BACKGROUND: Different opioids for use in the control of moderate to severe cancer pain have become widely available. More recently, sophisticated formulations such as transdermal patches have been developed. One example, transdermal fentanyl (TF), has characteristic pharmacokinetics and along with the other opioids, equivalency conversions are often made when changing from or to other opioids. AIM OF STUDY: To explore the knowledge of general practitioners (GPs), hospital consultants and oncologists about the pharmacology and use of TF in the management of moderate/severe cancer pain. METHOD: During 2001 and 2002 a questionnaire survey was carried out. A randomized selection of GPs, hospital consultants and oncologists (n=1167) from the UK and Ireland were sent a questionnaire and 576 (49%) were returned and evaluated. RESULTS: The results show doctors who had previously prescribed TF are more confident and knowledgeable about the indications and pharmacology of TF than doctors who had never prescribed TF. Overall knowledge and confidence in using TF was poor.